Dental Professionals

Medical and Dental Health History

Help us provide you with the best care possible by filling out the form below; please note items marked with a red asterisk (*) are required before beginning treatment.

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Which Office Location?*
Chicago Office Skokie Office
ID Code*

Please enter the ID Code you were provided by an employee of Dental Professionals of Old Orchard or Illinois Center Dental Associates.
First Name
Date of Birth MM/DD/YYYY
1) Patient Medical History
Physician
Office Phone
ext.
Approximate date of last physical examination MM/YYYY
If you don't know the exact date just put in your best estimate (e.g. 01/01/08)
Are you in good health?
Yes
Are you under medical treatment now?
Yes
What medical treatments and for what purpose?
Are you taking any medications now?
Yes
If so, which medicines and for what purposes?
Are you allergic to?
Penicillin
Yes
Other antibiotics
Yes
Codeine
Yes
Aspirin
Yes
Local Anesthetics
Yes
Latex Rubber
Yes
If you are allergic to any of the above please list any comments here
Are you taking birth control pills?
Yes
Are you pregnant?
Yes
How many months?
Are you nursing?
Yes
Have you ever had radiation treatment other than diagnostic?
Yes
Has a physician ever told you that you have (or had):

(check all that apply)
Heart Disease, Attack or Stroke
Yes
Angina Pectoris or chest pain
Yes
High or low blood pressure
Yes
Have you had a heart valve infection?
Yes
Artificial Valves
Yes
Artificial Joints
Yes
Heart Pacemaker
Yes
Anemia
Yes
Kidney trouble
Yes
Ulcers
Yes
TB or Lung Disease
Yes
Asthma or Hay Fever
Yes
Sinus trouble
Yes
Allergies or Hives
Yes
Diabetes
Yes
Thyroid problems
Yes
Cancer or Leukemia
Yes
Arthritis
Yes
AIDS or HIV+
Yes
Prolonged Sore Throat
Yes
Enlarged Lymph Nodes
Yes
Bleeding problems
Yes
Hepatitis A, B, or C
Yes
Blood Transfusion
Yes
Hemophilia
Yes
Epilepsy
Yes
Fainting or dizzy spells
Yes
Sickle Cell Disease
Yes
Sexually Transmitted Disease
Yes
Drug or Alcoholism
Yes
Smoke or Chew Tobacco
Yes
Please list any disease, condition or problems not listed above:
1) Have you been told or are you aware that you have a tendency for snoring?
Yes
- 1.a) Do you wake feeling rested after 7-8 hours of sleep?
  Yes
- 1.b) Do yo feel like you are 'dragging' during the day?
  Yes
2) Have you been observed to gasp for breath during sleep?
Yes
3) Have you been told that you have obstructive sleep apnea?
Yes
4) Are you interested in learning more about an oral appliance that could be beneficial?
Yes
2) Patient Dental History

(please check all that apply)
Have you experienced growth or sore spots in your mouth?
Yes
Have you experienced any prolonged bleeding following extractions in the past?
Yes
Do you chew on one side of your mouth?
Yes
Do you notice any clicking or popping of your jaw?
Yes
Acid reflux?
Yes
Have you noticed:
Bad breath?
Yes
Pain in or near ears?
Yes
Headaches?
Yes
Bleeding gums?
Yes
Spaces developing between teeth?
Yes
Food catches between your teeth?
Yes
Facial muscles feel tired?
Yes
Do you clench or grind your teeth while sleeping or during the day?
Yes
Have you ever received instructions in the care of your teeth and gums?
Yes
Have you ever been treated by a periodontist?
Yes
Have you ever been treated by an Orthodontist?
Yes
When was your last dental visit? MM/DD/YYYY
If you don't know the exact date just put in your best estimate (e.g. 01/01/08)
When was your last full mouth set of x-rays taken? MM/DD/YYYY
If you don't know the exact date just put in your best estimate (e.g. 01/01/08)
If you are having discomfort, please describe the problem:
Please add anything you feel is important:

Smile Consultation

I am interested in improving the appearance of my smile
If yes, which of the following do you feel would improve your smile:
Teeth whitening
Repair chipped or broken teeth
Close spaces
Straighten teeth
Do what is necessary to give me the best smile possible

Patient Comfort
Are any of these procedures uncomfortable or stressful for you?
Ultrasonic scaler (Removal of tartar by ultrasconic vibration & water)
Flossing
Polishing
Hand scaling (Removal of tartar by hand)
Prophy Jet (Removal of stain by air with pumice)
X-rays
Which of the following would help make your visit more comfortable?
Watching T.V.
Listening to a CD on a headset
Local or topical anesthetic
Other comments:

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Dental Professionals

Medical and Dental Health History

There was a problem with your submission.

1) Patient Medical History

Are you allergic to?

Has a physician ever told you that you have (or had):

2) Patient Dental History

Have you noticed:

Smile Consultation

Patient Comfort